Biologics in psoriasis

With newer biologics enriching the armentarium of Dermatologists almost everyday,it is often difficult to recollect all the information at a time.This powerpoint helps to summarise the pathogenesis of psoriasis as well asdifferent aspects of use of biologics in a nutshell.

1. BIOLOGICS IN PSORIASIS DR. Ananya Chandra MD( Dermatology,Venereology & Leprosy )

2. ELIGIBILITY CRITERIA Severe disease Fulfil at least one of the following clinical categories When phototherapy or alternative standard systemic therapy are contraindicated Intolerant to standard systemic therapy Unresponsive to standard systemic therapy Have significant comorbidity which precludes the use of standard systemic therapy Severe,unstable , life threatening disease

3. STEPS WHILE STARTING BIOLOGIC AGENT Counselling Pre-treatment history & investigations Planning vaccination Choosing biologics

4. WHICH ONE TO CHOOSE Rapidity of response desired Comorbidities Facilities Administering biologic Cost Follow up

5. WHICH ONE TO CHOOSE Rapidity of response desired Comorbidities Facilities Administering biologic Cost Follow up

6. CHOICE OF BIOLOGICS WITH COMORBIDITIES COMORBIDITIES BIOLOGIC Tubeculosis Secukinumab HBV/HCV Secukinumab HIV Etanercept Psoriatic arthropathy Adalimumab / Secukinumab Multiple sclerosis Secukinumab CHF Secukinumab

7. CHOICE OF BIOLOGICS WITH COMORBIDITIES COMORBIDITIES BIOLOGIC Coronary artery disease Anti- TNF α therapy IBD Anti- TNF α therapy Autoimmune disease Use biologics with caution CLD of noninfectious etiology Etanercept / Adalimumab CRF Etanercept Cancer No data available Obesity Secukinumab

8. AT A GLANCE DRUG DOSING SCHEDULE TOXICITY ETANERCEPT 25/50 mg twice weekly sc for 12 weeks and then weekly Inj site reactions, URTI,Lupus like syndrome,CHF worsening,TB reactivation ADALIMUMAB 80 mg on D1 f/b 40 mg every other week Inj site reaction,reactivation of TB INFLIXIMAB 3-5 mg/kg 0,2,6 wks and 8 wkly thereafter Infusion reactions,ADA,reactivation of TB ITOLIZUMAB 1.6mg/kg as IV infusion every 2 wk for 12 wk f/b once in 4 wk for 24 wk Acute infusion reaction,diarrohoea SECUKINUMAB 300 mg sc 0,1,2,3,4 wk f/b monthly maintainence dose Nasopharyngitis , Candidiasis , Neutropenia

9. COMBINATION WITH BIOLOGICS BIOLOGIC NBUVB MTX ACITRETIN CsA ETANERCEPT Rescue therapy Faster clearence Decreased dose Rescue therapy (?) ADALIMUMAB Rescue/bridge/concomitant/maintenance No studies Decreased dose Rescue therapy (?) INFLIXIMAB Rescue therapy (?) Decreased ADA Rescue/ Maintenance therapy Avoid SECUKINUMAB No studies No studies No studies No studies

10. BIOLOGICS IN SPECIAL SITUATIONS ETARNACEPT ADALIMUMAB USTEKINUMAB INFLIXIMAB ETARNACEPT ADALIMUMAB INFLIXIMAB

11. SWITCHING BIOLOGICS INEFFICACY ADVERSE EFFECTS Can be switched over to different drug of same class or new class Switched over to drug of NEW CLASS (infectious complications, CHF, multiple sclerosis while on TNF α blocker) OR drug of SAME CLASS ( e.g -in case of ADA)

12. INDICATIONS OF STOPPING BIOLOGICS Fail to achieve adequate response A serious adverse effect Pregnancy(temporary withdrawal) Elective surgical procedure(temporary withdrawal)

13. HOW LONG TO USE?????????

14. Upcoming Biologics DRUG TARGET IXEKIZUMAB IL17A BRODALUMAB IL17RA GUSELKUMAB IL-23p19 TILDRAKIUMAB IL-23p19 RISANKIZUMAB IL-23p19 CERTOLIZUMAB TNF α BIMEKIZUMAB IL17A&F NEIHULIZUMAB CD162 on TCELL NAMILUMAB GM CSF BRIAKINUMAB IL 12 & 23 MIRIKIZUMAB IL-23p19

15. TAKE HOME MESSAGE Psoriasis has tremendous psychosocial impact. Insights into immunopathogenesis of psoriasis have led to discovery of numerous new therapies. Biologics are a better treatment option with improved outcomes Amongst all the biologics, SECUKINUMAB provides the highest efficacy and QOL response with a favourable safety profile